RN Prior Authorizations

Core duties and responsibilities include the following. Other duties may be assigned.

Supports and encourages others to support the Mission, Core, Values and Goals of Prestige Health Choice.

Conducts occasional facility on-site and/or telephonic concurrent reviews and discharge planning and coordination of assigned hospitals.

Collaborates with follow up appointment coordination activities, and makes necessary referrals to medical and behavioral complex case managers .

Coordinates and supports all discharge authorization and service coordination activities necessary for discharge including inpatient hospital admissions, inpatient rehabilitation services, skilled nursing admission, home care, home care infusion services, outpatient and /or inpatient elective surgery, and referrals for physician consultation with nonparticipating physician offices.

Collaborates with health partners and behavioral Health partners with care coordination, transitions of care, discharges activities and member service issues

Attends facility and health center clinical and provider meetings.

Participates in daily facility rounds, and respective customer clinical and provider services meetings.

Collaborates with hospitalist’s networks, and reviews network performance and access.

Monitors performance metrics and operations reports such as bed day, LOS, daily census, discharge and high risk reports.

Assists in coordination of PCP appointments for members prior to discharge

Collaborates with member services and provider operations for network access, authorization inquires, and care coordination.

Collaborates with contracted customer representatives and clinical staff to coordinate and address service and care issues.

Provides operations, performance and summary reports to Director of Inpatient Services.

Meets with Director of Inpatient Services as needed for census and operational updates.

Meets as needed with customer hospitalist networks.

Performs other related duties and projects, as assigned.

**Interqual experience required**

Prior Authorization or concurrent review and case management experience for a health plan/managed care company (at least 3 years)

Knowledge of Windows and Microsoft Office applications.

Current and unrestricted Florida RN license.

Case management and health education experience preferred.

Community and public health experience preferred.